Krishna R. Patel, PharmD, RPh

Payers who intend to improve patient outcomes while decreasing inappropriate drug utilization in oncology care are positioned to implement clinical pathways now more than ever before.

Prior authorization is a commonly used management strategy that is effective to a certain degree, but there is still room for improvement. Payers and practitioners alike agree that the ideal management strategy should enable practitioners to take the wheel in selecting a patient’s pharmacotherapy, which prior authorization can inhibit.

Clinical pathways can help to reduce the need for prior authorization as a management strategy while satisfying oncologists’ needs. The figure “Pathways to prior authorization goals” shows how goals of prior authorization can be met by clinical pathways.

Pathways to prior authorization goals

The 50% of plans across the nation that have already implemented pathways or plan to do so soon see that the greatest return on investment of clinical pathways is for cancer diagnoses that are most prevalent and/or are associated with the highest drug cost.

The figure below shows the most common tumor types for which pathways have been developed by health plans.

Tumor types that are most often addressed by clinical pathways

Proportion of payers

Source: “Payers Working Collaboratively With Providers to Adopt Clinical Pathways and New Care Delivery Models,” Journal of Oncology Practice, Vol. 9, issue 2

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.